Att 3e_Sample Provider Demographic Survey

Form Approved

OMB No. 0920-1091

Exp. Date XX/XX/XXXX

3e Sample Provider Demographic Survey

Using Rapid Assessment Methods to Understand Issues in

HIV Prevention, Care and Treatment in the United States

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1091)

Provider Demographic Questionnaire

Clinic ID:______ Participant ID:________ Data Collector ID:_______

Date:_________ Start time: __:__am/pm End time:__:__am/pm

Instructions: Please complete the demographic questionnaire to the best of your abilities. If there are any questions you would prefer not to answer, you can skip to the next.

Funding for this study is provided by the Centers for Disease Control and Prevention (CDC).

DEMOGRAPHICS (2 min)

1. How old are you?

1. Under 18 years old STOP INTERVIEW

2. 18 – 25 years old

3. 26 – 35 years old

4. 36 years and over

2. Are you Hispanic or Latino/a?

No 0

Yes 1

3. What is your race? (Select all that apply.)

American Indian or Alaska Native 1

Asian 2

Black or African-American 3

Native Hawaiian or other Pacific Islander 4

White 5

4. Do you communicate in another language besides English to provide medical care (e.g., without the use of an interpreter)?

No 0 ® Please skip to Q6

Yes 1

5. In what other language/s do you provide medical care?

Spanish 1

Other 2 ® Please specify: _______________________________________________

6. What is your gender identity?

Male 1

Female 2

Transgender Male 2

Transgender Female 3

Other 3

7. Do you think of yourself as:

Homosexual, gay, or lesbian 1

Heterosexual or straight 2

Bisexual 3

Other 4

PROVIDER BACKGROUND (4 min)

8. How long have you been providing care for HIV-infected patients ________ years

(not including time in professional training)?

9. For how many HIV-infected individuals do you currently provide continuous medical care? ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­____________

10. How long have you been practicing at this healthcare facility? ____________ years

11. What is your profession?

Physician 1

Nurse Practitioner 2 Please skip to Q 14.

Physician Assistant 3 Please skip to Q 15.

Registered Clinical Nurse Specialist 4 Please skip to Q 14.

Registered Nurse 4 Please skip to Q 14.

Case Manager 5 Survey completed, skip to interview

12. Are you board certified in any of the following? (Select all that apply and indicate year of certification or most recent recertification, if applicable.)

Internal Medicine 1

Family Practice 2

Pediatrics 3

Infectious Diseases 4

Obstetrics and Gynecology 5

Neurology 6

Dermatology 7

Surgery 8

Hematology-Oncology 9

Immunology 10

Other board certification 11

Please specify: ______________________________

Physicians skip to Q 15

13. Are you certified by the HIV/AIDS Nursing Certification Board as an AIDS Certified Registered Nurse (ACRN) or an Advanced AIDS Certified Registered Nurse (AACRN)?

No 0

Yes 1

14. Are you a member of any of the following professional organizations? (Select all that apply.)

American Academy of HIV Medicine (AAHIVM) 1

HIV Medicine Association (HIVMA) 2

American Association of Nurses in AIDS Care (ANAC) 3

International Association of Providers of AIDS Care (IAPAC) 4

15. Do you have American Academy of HIV Medicine (AAHIVM) specialist certification (AAHIVS)?

No 0

Yes 1